MEDICARE: VAUGHAN R WIMBERLEY LCSW-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	23796	MD
2	1041C0700X	Clinical Social Worker	23796	MD

General Provider Information

NPI Number	:	1275025926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VAUGHAN R WIMBERLEY LCSW-C

Provider Business Mailing Address
First Line	:	3500 BOSTON ST STE 421
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21224-5281
Country	:	US
Telephone Number	:	410-907-7656
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 BOSTON ST STE 421
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21224-5281
Country	:	US
Telephone Number	:	410-907-7656
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2018
Last Update Date	:	05/06/2022

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